Background Stroke survivors have high rates of mortality and recurrent stroke. Stroke patients are often unable to participate in decision making, highlighting the need for advance care planning ( ACP ) in poststroke care. We sought to better understand experiences and perceptions around stroke risk and ACP in our stroke clinic. Methods and Results Clinic patients completed the Planning After Stroke Survival survey assessing (1) advance directive ( AD ) documentation and ACP conversations, (2) factors associated with ADs and ACP , (3) perceptions of stroke risk, and (4) ACP needs. We used a physician survey and the electronic medical record to assess clinical and demographic information. We collected 219 surveys (78% response rate). Forty‐five percent reported having completed ADs , although the correlation between patient report and EMS documentation of ADs was low. Most patients (73%) had discussed ACP , and 58% desired additional conversation. Predictors of completing ADs included age (≥65 years; odds ratio, 4.8; 95% CI, 2.3–10.1), white race (odds ratio, 3.1; 95% CI , 1.2–7.8), milder poststroke disability (modified Rankin Scale score ≤1; odds ratio, 2.9; 95% CI , 1.3–6.4), having previously discussed ACP with a physician (odds ratio, 4.8; 95% CI , 2.0–11.7), and discussing risk of stroke recurrence (odds ratio, 2.2; 95% CI , 1.1–4.5). Conclusions Stroke survivors had low AD completion rates and desired more conversations about stroke risk and ACP . Completed ADs were inconsistently documented in the electronic medical record. These findings provide guidance to improve ACP in our stroke clinic and may provide a model for others interested in enhancing ACP and ultimately goal‐concordant care.

Background and Purpose— Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea may improve stroke recovery, but adherence is poor. We assessed the effectiveness of an intensive CPAP adherence program during and after inpatient stroke rehabilitation on 3-month adherence and stroke recovery. Methods— In a single-arm study, 90 stroke rehabilitation patients were enrolled into an intensive CPAP adherence program. CPAP was continued after a run-in among qualifying patients with evidence of obstructive sleep apnea. The primary outcome was CPAP adherence, defined as ≥4 hours of use on ≥70% of days, over 3 months. Results— A total of 62 patients qualified for continued CPAP and 52 of these were willing to continue CPAP after discharge from rehabilitation. At 3 months, the average daily CPAP use was 4.7 hours (SD 2.6), and 32/52 (62%) patients were adherent. Factors significantly associated with adherence included more severe stroke, aphasia, and white race. Compared with nonadherent patients, adherent patients experienced greater improvements in the cognitive component of the Functional Independence Measure ( P =0.02) and in the National Institutes of Health Stroke Scale ( P =0.03). Conclusions— This intensive CPAP adherence program initiated during stroke rehabilitation can lead to CPAP adherence in the majority of patients with evidence of obstructive sleep apnea, including those with more severe stroke and aphasia, and may promote recovery. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02809430.

Patient: Male, 42Final Diagnosis: Henoch-Schönlein Purpura (HSP)Symptoms: Bullous hemorrhagic lesions • elevated liver enzymesMedication: —Clinical Procedure: —Specialty: RheumatologyObjective:Unusual clinical courseBackground:Henoch-Schönlein Purpura (HSP) is an IgA small-vessel vasculitis that is primarily a disease of childhood. Its presentation in adulthood is rare and has a more severe disease course. We present a case with an atypical presentation of this disease that was a diagnostic challenge for multiple providers.Case Report:A 42-year-old man noticed bullous lesions over his ankles that spread to his entire legs over a few weeks. They later became necrotic and ulcerated areas. His primary care physician and 2 dermatologists could not reach a definitive diagnosis. He then presented to our hospital with new abdominal pain, rectal bleeding, and a new elevation in liver enzymes. A biopsy of his skin lesions led to the diagnosis of HSP.Conclusions:We discuss this highly unusual initial presentation with bullous skin lesions and liver enzyme abnormalities and explore the medical literature to understand its pathogenesis. Clinicians need to be aware of this rare presentation to avoid a delay in diagnosis and management.

Introduction: Stroke is the 2 nd most common cause of death and the leading cause of disability worldwide. Stroke survivors have high rates of comorbid medical conditions; one in 5 stroke survivors will suffer a recurrent stroke within 5 years, and a TIA doubles the risk for heart attack. In the acute stroke setting, patients are frequently unable to participate in their own medical decision making. Therefore, advanced care planning (ACP) should be a fundamental part of post-stroke care. Methods: We surveyed stroke survivors and stroke physicians in our tertiary care stroke clinic as part of a quality improvement program. All new and follow-up patients were invited to complete a 12 question survey on ACP, including history of relevant discussions and perceived risk of recurrent stroke or disability. Stroke physicians documented demographic data, NIHSS, any acute treatment received, mRS and provided a risk estimate for recurrent stroke or death. Results: Between March and July 2017, 198 surveys were completed. Median age was 61 years (IQR 50-70), 94 (47.5%) were female, and 61% presented to the stroke clinic for the first time after their stroke. The majority (55%) had an initial NIHSS of 5 or less, and 10% had received IV tPA or thrombectomy during their acute stroke care. At the time of follow-up, median mRS was 1 (IQR 0-2). Almost ¾ (n=145) had had a conversation with a physician about ACP, and 110 (56%) wanted to discuss ACP with their stroke physician. Less than one half (n=88) had advance directives (AD) in place. Patients were significantly more likely to have AD if they were white (53% compared to 24% in all other races, p<0.001) and less disabled (55% for those with mRS 0-1 compared to 31% in those with mRS ≥ 2 (p=0.002). Having discussed their risk of recurrent stroke with a physician was also associated with higher rates of AD (58% vs 37%, p=0.004). Conclusions: Most patients presenting to stroke clinic do not have advance directives, but a willingness to discuss ACP is common. We identified certain groups who were less likely to have advance care plans. Our findings suggest that the stroke clinic may be an optimal setting for a targeted intervention to increase access to ACP.